QA Investigation Results

Pennsylvania Department of Health
AVEANNA HEALTHCARE
Health Inspection Results
AVEANNA HEALTHCARE
Health Inspection Results For:


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Initial Comments:

Based on the findings of an unannounced state licensure survey conducted on November 1, 2018 2018, Aveanna Healthcare was found to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601.




Plan of Correction:




Initial Comments:

Based on the findings of an unannounced state licensure survey conducted November 1, 2018 2018, Aveanna Healthcare was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, and Subpart A. Chapter 51.




Plan of Correction:




51.3 (g)(1-14) LICENSURE
NOTIFICATION

Name - Component - 00
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.


Observations:

Based on the review of the agency documentation and the Pennsylvania Department of Health ' s Event Reporting System, and interview with executive director and the director of nursing, the agency did not report findings of alleged abuse in compliance with Pennsylvania state law by a home health aide.
Findings include:
Review of Act-13 of 1997 requires an employee or administrator of a facility who has reasonable cause to suspect that a recipient is a victim of abuse to immediately report the abuse. The effective date was December 10, 1997.
"Employees and/or administrators who have reasonable cause to suspect that a recipient is a victim of any of the types of abuse described below shall immediately make an oral report to the Area Agency on Aging (AAA). In addition to reporting to the AAA, oral reports must be made to the Pennsylvania Department of Aging (PDA) and local law enforcement for suspected abuse involving sexual abuse, serious physical injury, serious bodily injury or if a death is suspicious.
Within 48 hours of making all oral reports, the employee or administrator shall make a written report (on forms prescribed by PDA as mandated by Act 13) to the AAA. The AAA will forward a copy of the written report to the Department of Aging within 48 hours for all reports involving sexual abuse (not including sexual harassment), serious physical injury, serious bodily injury and suspicious death."

Review of Pa. Code, Part IV, and Health Facilities and Subpart a Chapter 51 states: "51.3 Notification (f) if a health care facility is aware of a situation or the occurrence of an event at the facility which could seriously compromise quality assurance or patient safety, the facility shall immediately notify the Department in writing. The notification shall include sufficient detail and information to alert the Department as to the reason for its occurrence and the steps which the health care facility shall take to rectify the situation.
51.3 Notification
(g) For purposes of subsections (e)
And (f), events which seriously compromise quality assurance and patient safety include, but not
Limited to the following:
(1) Deaths due to injuries, suicide or unusual circumstances.
(2) Deaths due to malnutrition, dehydration or sepsis.
(5) Transfers to a hospital because of injuries or accidents.
(6) Complaints of patient abuse, whether or not confirmed by the facility."

Review of agency policy on November 1, 2018 at 1430 titled " Abuse-Neglect-Exploitation Identification and Reporting " states "All reports are made to the local director/administrator of the local office. The Director or designee is responsible for ensuring any suspicions of abuse, neglect or exploitation are reported to the appropriate authorities or agencies.
Agency policy failed to include the reporting to PA Department of Health through the Event reporting system (ERS) based on PA Chapter 51 regulations as a mandatory reporting for complaint of patient abuse, confirmed or not, misappropriation of patient property and falls witnessed by employees.
Review of complaint log on November 1, 2018 at 1430 revealed event was not reported to PA Department of Health through the Event Reporting System (ERS):
Report of alleged abuse by a home health aide when discovered on May 15, 2017.
Review of Pennsylvania Department of Health -Event Reporting System by this surveyor as part of preparation for complaint investigation survey on October 30, 2018 and November 2, 2018 revealed that home health agency did not report any events since April 2013, no events reported in 2014 and none as of July 2015.
Interview with the administrator and director of nursing on November 1, 2018 at 1530 confirmed the above findings.





Plan of Correction:

Plan: All Clinical Supervisory staff and Directors will be re-educated regarding which incidents are categorized as a qualifying event to the Department of Health.

Who is responsible: Nursing Director (Executive Director as back-up) and Nursing Supervisors.

Completion Date: 12/20/2018

Follow up: QA tracking is done monthly as well as meetings quarterly. At that time, all incidents will be reviewed by the Nursing Director (ED back-up) to ensure compliance.


Initial Comments:

Based on the findings of an unannounced on-site state licensure survey conducted November 1, 2018 2018, Aveanna Healthcare was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: